Behind the oxygen mask, his eyes have the panicked, haunted look of a man who can’t breathe. ...... Nepal’s air quality ranks 177th out of 178 countries, according to Yale’s 2014 Environmental Performance Index (EPI), better only than Bangladesh. As a physician working in one of Kathmandu’s main teaching hospitals, I see a disproportionate amount of patients with respiratory ailments who are admitted to the wards on a daily basis, the victims of dirty air. Walking to and from work along the crowded, exhaust-choked streets, I sometimes wonder how more people are not sick. ...... Those new to Kathmandu frequently complain of sore throats and itchy eyes within a few days of arrival. ...... during surges in Kathmandu traffic congestion, the level of small particulate matter can measure over 500 micrograms per cubic metre, or 20 times the World Health Organisation’s safe upper limit. ....... For smokers with COPD, one of the only effective interventions that improves longevity is to quit smoking. But Ajay and those like him have no cigarettes to give up. The air they breathe is making them sick. For them, the question of whether the city will become unliveable is moot. It already is.

Nepal's failed development
Nepal is one of the best examples of failed development aid - so why do the donors keep pumping more money in?

A decade of Maoist insurgency from 1996 to 2006 killed 17,000 people and hindered economic activity. Yet during the conflict GDP growth fluctuated within a similar range to before and after. Infrastructure was destroyed, but there wasn't much in the first place and - thanks to public corruption - much of it has been rebuilt twice-over. The quality of village schools and health posts was as wretched before the war began as it is now, almost a decade since it ended. Nepal suffered conflict, but many Asian countries that have developed more successfully have suffered worse. .........

For the most part, of course, the country's rulers are to blame - and they have conducted themselves in a similar manner for decades.

...... the government is run as an extractive enterprise, in which the various parties and factions are built on pyramids of graft, commissions, and the sale of offices. Useful public institutions such as the education ministry, the university, the electricity board, the national airline, or the airport, have been hollowed out and left semi-functional. ....... In the private sector, the party bosses give political backing to cartels, syndicates and "mafias" which, for example, manipulate prices and operate monopolies in the drinking-water, food, transport and energy markets. They profit from the fact that the health and education sectors are dysfunctional. ..... Despite the donors' talk of Nepal being "fragile", there is in fact notability stability at the heart of the state, both in the way it works and the individuals who run it. Most have careers at the top spanning decades, and many are the children or relatives of other powerful people. ....... The donors are also wrong to believe (as they often do) that the government "doesn't understand" what it is doing, or "needs educating". When it comes to serving their own interests, and those of their core constituents, the country's leaders are successful. Unfortunately for most Nepalis, providing "development" for the wider public is often in conflict with those interests. ...... Despite rampant mismanagement, and a splurge at the end of every year timed to escape scrutiny, around a quarter of the funds reserved for capital investment remain unspent annually. ......

The public perception is of a great deal corruption not only in government, but in the development industry itself.

..... The main reason for recent progress in poverty alleviation is clearly remittances from migrant labourers, which have risen rapidly to be worth around 25 per cent of GDP. Nepali workers go abroad because the domestic economy is ruined, and the money they send home is spent on private health and education, because the donor-supported public sector is useless. ....... Nepal's problem is not a want of aid or technical advice. It is political. And if the donors are to be part of the solution, they must be brave enough to publicly demand meaningful action against the entrenched public corruption, the cartels, "syndicates" and "mafias" which are keeping the country poor

There is a concrete mathematical theory called the butterfly effect. A butterfly flapping its wings in the Amazon forest could be the reason a cyclone hit Bangladesh. What happened in Nepal in April 2006, January-February 2007, and February 2008 were political cyclones. I was the butterfly flapping my wings in New York City. In April 2006, over a period of 19 days, about eight million people out of the country's 27 million came out into the streets to shut the country down completely to force a dictator out.